Guam § 2916 - Medically Indigent Program Reimbursement Fee Schedules for Providers.

§ 2916. Medically Indigent Program Reimbursement Fee Schedules for Providers.

(a) Reimbursements to Providers and Non-Providers shall be in amounts not to exceed the following:

(1) for in-patient hospital services, the Program shall reimburse services in accordance with the

annual Medicare per diem rates set for the hospital’s in-patient services;

(2) for out-patient hospital services, the Program shall reimburse a hospital by applying the annual

Medicare hospital specific out-patient cost-to-charge ratio to the covered charges;

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(3) for skilled nursing services, the Program shall reimburse at fifty percent (50%) of the annual

Medicare per diem rates set for the hospital’s in-patient services;

(4) for intermediate care services, the Program shall reimburse services at sixty percent (60%) of

reimbursement rate established in § 2916(a)(3) for skilled nursing;

(5) for professional fees and home health services, the Program shall reimburse services at one

hundred percent (100%) of the Medicare Participating Provider fee schedule rate adjusted in

accordance with the Hawaii or Guam conversion factor as applicable; and

(6) for dental fees, the National Dental Advisory Schedule shall be used to reimburse services.

(b) The Administrator of the Medically Indigent Program shall have discretionary authority to

establish Provider and Non-Provider reimbursement rates for services which are not specifically addressed

herein, but which are consistent with the Program services provided by § 2901 through § 2915 of this

Article. Said schedules will be developed in conjunction with the Administrator’s duties to secure the

necessary Provider and Non-Provider relationships to ensure the availability of adequate medical care and

assistance to all Program recipients.

(1) The Program shall not pay claims for Program-covered services that are initially submitted

more than twelve (12) months after the date of the service as clean claims, except for claims submitted

for services to members involving the coordination of benefits amongst multiple payers.

(2) Payments shall be made on clean claims in accordance with the reimbursement rates set forth

in this Section.

(c) “Clean claims” as defined by this Article and as further defined herein shall mean:

(1) For a Hospital Bill. A hospital bill is considered received for purposes of this Subsection upon

initial receipt of the legible claim form by the administration if the claim includes the following error-

free documentation in legible form:

(A) an admission face sheet;

(B) an itemized statement;

(C) an admission history and physical;

(D) a discharge summary or an interim summary if the claim is split;

(E) an emergency record, if admission was through the Emergency Room;

(F) operative reports, if applicable;

(G) a labor and delivery room report, if applicable;

(H) utilization review report.

(2) For Medical Service Claims. For medical service claims, a claim that is submitted on a HCFA

1500 reflecting CPT and HCPCS codes for services and supplies. Services requiring prior

authorization shall have a copy of the approved authorization form attached. Specialist services shall

have the appropriate referral form attached.

(3) For Dental Claims. For dental claims, a claim that is submitted on the ADA claim form

reflecting proper codes for services.

(4) For Behavioral Health Forms. For behavioral health forms, a claim submitted on a HCFA

1500 reflecting CPT codes for behavioral health services.

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(d) Payment received by a Provider or Non-Provider from the Program is considered payment by the

Program of the Program’s liability for the member’s bill. A Provider may collect any unpaid portion of its

bill from other third party payers or the member in the event of non-covered services. A Provider or Non-

provider shall not:

(1) charge, submit a claim to, demand or otherwise collect payment from a member or person

who has been determined eligible, unless specifically authorized by this Article or rules adopted

pursuant to this Article; or

(2) refer or report a member who has been determined eligible to a collection agency or credit

reporting agency for the failure of the member to pay charges for Program covered care or services,

unless specifically authorized by this Article or rules adopted pursuant to this Article.

(e) The Administrator may conduct post-payment review of all claims paid by the Program and may

recoup any monies erroneously paid.

(1) The Administrator shall adopt rules that specify procedures for conducting post-payment

review.

(2) The Program Administrator shall review all prepaid captivated payments and may conduct a

post-payment review of all claims paid by the Program, and may recoup monies that are erroneously

paid.

(A) Any Provider receiving reimbursements under this Article for which they were not

entitled on the basis of false claims filed on behalf of any person receiving assistance under this

Article shall be liable for repayment, and shall be guilty of a misdemeanor or felony, depending

on the amount paid for which the person was not entitled, as specified in the Criminal and

Correctional Code of Guam, Title 9 of the Guam Code Annotated.

(f) Claims for Program-covered services which are determined valid by the Administrator pursuant to